GW1--05599_Well Construction - GW1_20230825

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WE LL CONSTRUCTION 'CORD(GW4) For Internal Use Only. �. _..:..._,_...,__,...._
1.Well Contractor Information:
Chris King 14.WATER ZONES 1
Welt Contractor Name FROM TO DESCRIPTION
2080-A 76 it. 7/ ft. 2 0 I 6.a pi rn
•
fr. ft
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased welts)OR LINER(if ap licable)
Aqua Drill,Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name c, ft. 4.1 3 ft. 6.5fs.1 in. a 1 g y 6,_101 _
16.INNER CASING OR TUBING(geothermal closed loop) rs
2.Well Construction Permit if: 5 e2(-) 1 (--4-)C1-W 2 a2- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. it. ,In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
II�A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1_I gri ' OMunicipal/Public ft. ft. in.
[Geothermal(Heating/Cooling Supply) EtResidential Water Supply(single) ft ft. in.
11Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: 0 ftslO l
ft ;3 +
'� �Z�YIJ -t`11I915
Monitoring Recovery it, ft.
Injection Well:
Aft.Rechargeft. R.
q IOOGroundwaterRemediation
®IAquifer Storage and Recovery I Salmi Barrier 19.SAND/GRAVEL PACK(If applicable)
tY FROM TO MATERIAL EMPLACEMENT MErHOD
[IDAquifer Test fOIStormwater Drainage it ft.
EDExperimental Technology IOSubsidence Control ft. H. .
DGeothemlal(Closed Loop) IDTiacer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hsrdaess aollfracktype,grain eta eta)
4.Date Well(s)Completed: p -I['1 •Zl IDi
' Wel #!NO 4 f> ft• it _I �C i lC r
6 ft V 26 fr• 5141ts G g t%f,r
5a.Well Location: 2.0 ft. ft.
ib.--ri C C 05441it. MbMe$ ft. ft.
Facility/OwnerName Facility ID#(if applicable) ft. ft.
,5060 ►4 P iZ0e54-ifis r-c,3 0 12.. ft. It. 1:<sd _.e i'' ;�1I i )
Physical Address,City,and Zip ft t f
ill- 1A1'1't'1'ica 21.REMARKS Am; Y. j2 iU)1
County Parcel Identification No.(PIN)
Illtarma.0 CD r•t c:czo.v:rj lira
501 Latitude and longitude in degrees/minutes/seconds or decimal degrees: De" 'm 9.?
(if well field,one latllongis sufficient) 22.Ceetlf ation:
•
N W (J '9
- I `I 23
6.Is(are)the well(s, !"ermanent or Temporary Signature of Certified Well Contractors Date
By signing this form,I hereby certlfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ;$Yes ore0.o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standen*and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional welt details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPR'or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
I
9.Total well depth below land surface: (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells Ito all depths ijdperent(example-3ta�00'and 2@1003
construction to the following: l'
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,If waterlevel is above casing,use"-1- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: co (In.) 24b.For Infection Wells: In addition`to sending the form to the address in 24a
12.Well construction method: /�)aIZ; 1 above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following
FOR WATER SUPPLY WELLS ONLY: 1636
of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield ni) �
(�P Method of test: . i t yl-' 24e.For Water Sunoly&injection Wells: In addition to sending the form to
��y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:,� T/"F Amount: 0 Z., completion of well construction to the I county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016